Standing Committee E

[Mr. Peter Atkinson in the Chair]

Health and Social Care (Community Health and Standards) Bill

Schedule 1 - Constitution of public benefit corporations

Amendment moved [this day]: No. 97, in 
schedule 1, page 93, line 9, at end insert 
 'and shall define ''public constituency''.'.—[Sir George Young.]

Peter Atkinson: With this it will be convenient to discuss the following:
 Amendment No. 125, in 
schedule 1, page 93, line 12, leave out from 'area' to end of line 13 and insert 
 'covered by a primary care trust or primary care trusts for which the corporation is the principal provider of hospital based services, or'.
 Amendment No. 175, in 
schedule 1, page 93, line 15, leave out 'may' and insert 'shall'.
 Amendment No. 118, in 
schedule 1, page 93, line 17, after 'including', insert 
 'their family members involved in their attendance and care as patients or other'.
 Amendment No. 144, in 
schedule 1, page 93, line 17, at end insert— 
 '(2A) A ''carer'', for the purposes of subparagraph (2), means an individual aged 16 or over who provides or intends to provide substantial care on a regular basis for the patient and does not provide the care in question. 
 (a) by virtue of a contract of employment or other contract with any person; or 
 (b) as a volunteer for a voluntary organisation as defined in the National Assistance Act 1948.'.
 Amendment No. 119, in 
schedule 1, page 93, line 18, leave out 'Subparagraph (1)(a) does' and insert 
 'Subparagraphs (1)(a) and (2) do'.

George Young: I welcome you to the Chair, Mr. Atkinson. You will read in Hansard how a wave of excitement ran through the Committee when we heard the news of your appointment.
 Before we adjourned, I was speaking to my amendment on defining the constituency for the purpose of electing a foundation trust. I posed a number of questions not from a troublesome Opposition Back-Bencher, but from the Select Committee, which examined the Bill, the Secretary of State and others and concluded that the Bill is fragmented, confusing and inequitable. The Select Committee made a clear recommendation to resolve some of the issues that I was talking about this morning. It said that 
''it is imperative that the Government safeguards democracy throughout the NHS by providing a national set of guidelines specifying the rules for defining membership constituencies and the 
process for managing elections so that NHS patients, and the public at large, can have full confidence in transparent and consistent standards of involvement.''
 I want to know whether the Minister will be responding positively to the Select Committee's recommendation, which was couched in strong language and referred to safeguarding democracy and so on. 
 The Government's response so far has been to say that all the issues concerning defining constituencies is a matter for the trusts. However, the Select Committee said in its report that there is no reason why foundation trusts should be experts in community involvement. Fiona Campbell of the Democratic Health Network was quoted in paragraph 41 as saying that 
''trusts have no idea of what is involved in real community engagement''.
 The Select Committee made the point that they may not have a track record in community and patient engagement so far. 
 I am worried about all the tasks that we are imposing on foundation trust managements. They are supposed to run a quality service for the NHS, but we discovered this morning that the vehicle that they will have to drive has not been built and is still in the process of being designed. The Under-Secretary can provide no precedent for the corporate vehicle that is envisaged in the Bill. The Government will also have to push back the frontiers of democracy by finding a new way of involving people in running the NHS and inventing new constituencies. 
 I hope that the Under-Secretary will tell us that on the slender shoulders of the management will not be placed some of the burdens that I have described and that there will be clear guidelines. She may like to invite the Electoral Commission to shed some light on how to get that right. We have not touched on the voting process—how people will vote and so on—and we may come to that later. 
 I shall draw my comments to a close by saying that there is an important issue here. The Select Committee is not happy with the way in which the Government responded. I and others who have tabled amendments expect the Government to go further and we wait with mounting anticipation to hear how the Under-Secretary will respond to the case that my colleagues and I will make.

Andrew Murrison: I rise in support of my right hon. Friend's comments. I alluded to one constituency which needed special consideration and is a good exemplar of the sort of dilemmas that my right hon. Friend touched upon; the military constituency. We must give some thought to unusual groups such as those who use military district general hospital units, MDHUs. A good example is that in Selly Oak. The patient base for Selly Oak is many miles from Selly Oak and Birmingham and may be in Portsmouth or Aldershot. It is difficult to see from the Bill how patients from the military constituency will be represented at such hospitals. I hope that Ministers will focus on that specific example because the matter
 is of great concern to me as the Member of Parliament for a fairly military constituency.
 I hope that they will also examine the more general point of how to deal with non-straightforward constituencies. I suspect that once we scratch a little further at the conundrum, we will find that many hospitals have an unusual and not dissimilar patient base. We need to ensure that they, too, are properly represented. The example that I gave is quite a good one; for instance, if Selly Oak hospital became a foundation hospital, its governing body would have an interest in excluding that group of patients. 
 Something of a dialogue is always going on between the military and the NHS in the running of MDHUs. Indeed, I seem to remember that when they were being set up, the NHS had no great appetite for establishing MDHUs within their hospitals. I can foresee foundation hospitals seeking to exclude that particular part of its business, and they would have no incentive to include the military, as the constituency is defined by the hospital. The Health Committee's report on foundation hospitals was right to identity that problem, and it is for the Government to set the parameters when defining what is meant by ''constituency'' rather than leaving it to foundation hospitals.

Stephen McCabe: I, too, take the opportunity to welcome you to the Chair, Mr. Atkinson.
 I have talked to a lot of people about how we should define ''public constituency'', and I have a great deal of sympathy with the amendment tabled by the right hon. Member for North-West Hampshire. The Government's intentions may be good. I have no problem with the idea of decentralising hospitals and with giving them greater scope to innovate, to expand their capacity and to improve the care and treatment of patients; I am all for that. However, I wonder exactly how we can ensure that such public constituencies are genuinely representative. 
 The right hon. Gentleman alluded to the problems that might arise if particular groups were to attempt to pack the membership. He cited the example of people with radical health perspectives, but that could apply also to religious sects. Indeed, in one of the weekend newspapers, I read how the Socialist Workers party has been able to block reforms in some secondary schools by manipulating the views of certain teachers. I dare say that if Lady Olga Maitland, the erstwhile colleague of Opposition Members, were still alive and kicking, she would be happy to resurrect a militant Mothers Union in pursuit of something similar. [Interruption.] I always remember her being fairly robust. 
 We need to be clear that the public constituency will be fair in representing people, and that it will not be possible for groups to combine with the deliberate aim of subverting the health service's values and intentions. I hope that the Minister will be able to offer some reassurance, but nothing in the Bill suggests that it will. 
 The hon. Member for Westbury (Dr. Murrison) was right about the centre for defence medicine. The university trust's initial submission points out that the RCDM air commodore is currently part of the management executive of the trust. It would be a peculiar state of affairs if a military man were to be part of the existing management executive, but that the military had no significant status in the sort of public constituency defined in the Bill. We should be given an answer to that question. 
 Two other amendments struck me as interesting. Amendment No. 118 seeks to extend the provision to family members. That, too, seems appropriate, but we could end up with the bizarre situation in which the family member who regularly travelled from another part of the country to provide care and attention would be part of the public constituency but, were the amendment to be accepted, someone living a few miles down the road could be excluded. It is important that we cater for family members and those who provide direct care, but the amendment throws up the fact that we need greater clarity on how to define the public constituency and how to ensure that those involved have a say. 
 I am intrigued by amendment No. 119, which suggests that staff members would need to live in the area. I can see that that might be suggested if we were using a definition used elsewhere—the requirement to reside in a specified area—but it seems absurd to say that the staff should have a stake and an interest in the hospital, and therefore a right to participate, but only those who live within a defined area. That suggests that we do not have clarity on what constitutes a public constituency.

Andrew Lansley: I have not had the opportunity to explain the purpose and mechanism of amendment No. 119. However, its purpose is not what the hon. Gentleman suggests; rather, it would provide that the carers of patients who also happen to fall within the definition of employees of the corporation—in other words, they are part of the staff constituency—cannot be treated as part of the public constituency.

Stephen McCabe: I am grateful to the hon. Gentleman. I was referring to amendment No. 118. I apologise if I inadvertently referred to amendment No. 119.
 Whichever side one takes with the amendments, they have one thing in common; they highlight the confusion over what is an appropriate public constituency for the venture. The Minister could help allay the concerns of those who fear that this well-intentioned exercise may have unintended consequences. He would go a great way to allaying those fears if he were to give a much clearer description of what will constitute the public constituency, and say how he arrived at those decisions.

Simon Burns: I, too, echo what was said in your absence this morning, Mr. Atkinson, about what a pleasure it is to have you and Mr. Griffiths chairing our proceedings for the next 19 sittings.
 I wish to speak to amendments Nos. 125 and 144. They dovetail with amendment No. 97, moved by my right hon. Friend the Member for North-West Hampshire. I suspect that they also dovetail with the intentions of my hon. Friend the Member for South Cambridgeshire (Mr. Lansley). 
 My right hon. and hon. Friends and the hon. Member for Birmingham, Hall Green (Mr. McCabe) highlighted the confusion caused by the vagueness of the Government's proposals for the constituencies of corporations. Eligibility for membership extends to members of the public, people who live in the local area, people who live outside the area but were patients in the previous three years, and employees of the trust. On that last narrow point I have a question for the Minister. 
 Membership for employees of the trust is confined to those who have permanent contracts or fixed-term contract longer than 12 months. I do not expect the Minister to be able to tell me this afternoon, but what exactly is the position for NHS staff on short-term contracts? In particular, what proportion of NHS staff have contracts of less than 12 months? They will be excluded, but they spend a reasonable amount of time working at the hospital. 
 Those with short-term contracts of 12 months would be excluded because the provision says that the contract must be for longer than 12 months. What will happen to those who have contracts for 12 months whose contracts are renewed? I presume that when the constituency and its constituent bodies are being drawn up, they would not know that such contracts would be renewed. It would be unfair to disfranchise such people because of uncertainty about how the system works.

Andrew Murrison: Has my hon. Friend and, indeed, the Minister considered agency staff? For a variety of reasons—mainly to do with the environment in which we live—they represent an increasingly large proportion of the NHS work force. It would be extraordinary if such an important body of people were to be excluded from the staff constituency. What assessment have Ministers made of that?

Peter Atkinson: Order. Before the hon. Member for West Chelmsford (Mr. Burns) continues, we are anticipating the debate on the next group of amendments, which deal with staff contracts rather than the general constituency.

Simon Burns: I am grateful to my hon. Friend for raising that matter, but I take on board your valid point, Mr. Atkinson.
 The proposals are both vague and confusing. The explanatory notes deal with that at paragraph 48 on page 8. On paragraph 3 of schedule 1, which amendment No. 125 would change, the notes state that 
''each public benefit corporation is given the power to specify membership criteria in its constitution. The members must include individuals drawn from the public—the public constituency''.
 However, it is up to the benefit corporation to specify the membership criteria in its constitution. I find that slightly worrying because one will probably end up with different corporations specifying different criteria. I hope that Ministers agree that that would 
 not be satisfactory, because it will cause confusion and anger among those who might be excluded in one area but who would be included in another. We must have consistency throughout the country in order to avoid that sort of problem. 
 Members do not have different specifications as to who may or may not vote for us in our constituencies. It is an across-the-board national specification that an individual has the right to vote in an election provided he or she meets specific criteria laid down by law. We cannot pick and choose the groups or types of people who can vote. It would be unhealthy and unfortunate if that were to be the case under this arrangement. 
 Amendment No. 125 proposes a way of tightening up the system in order to give it greater clarity. That would deal not with the employees in the corporation but with the users and the population in the corporation area. I suspect that the Under-Secretary may come up with reasons as to why that would be too restrictive or why it would bring disadvantages that are not obvious to me at the moment. She will undoubtedly enlighten me in due course. 
 Even if that were to be the Under-Secretary's response, I hope that she would concede the reasoning and the motives behind the amendment, which are to try to achieve greater clarity and consistency. If she feels that that should not be achieved based on the geographical areas of a primary care trust, perhaps it should be achieved using other criteria that are an improvement on the vague position currently on offer. 
 As my right hon. Friend the Member for North-West Hampshire said, the Health Committee, which produced its report on foundation hospitals last Wednesday before Second Reading, had many reservations about the vagueness of the proposals. I hope that the Minister would consider it an advantage—she may not—that she has no less than three members of the Health Committee serving on this Committee to help her with her deliberations; the hon. Members for Leigh (Andy Burnham), for Lewisham, West (Jim Dowd) and myself. 
 I urge her to re-read the record of the Health Committee meetings because the Committee made some valid points on this problem. I will not repeat what my right hon. Friend said. However, the Committee is a Select Committee with a Labour majority and is not there to play games and cause trouble. [Interruption.] I note the Under-Secretary's facial expression and the one or two guffaws from Members. 
 The Health Committee is there to help the Government to improve on these proposals. The Under-Secretary will see in paragraphs 31 to 42 not only the criticisms and the points highlighted by my right hon. Friend, but points made by other people who agree with the concept of democratic accountability and the need to include as many relevant people as possible, but feel that by being so unspecific and giving too many powers to the corporations, the proposals will fall between two stools. In certain areas they will fail to achieve what the Government want and, thus, an inconsistent 
 system could be allowed to develop. That will cause grievances and create confusion and anger for individuals who may not be included in a constituency in a certain part of the country but who would be included otherwise. 
 Amendment No. 144 seeks to deal with line 17 of schedule 1, because the Government's proposals are vague. I see what they mean, but in order that legislation is good, it is not enough to simply see what the Government mean. Legislation must be absolutely spot-on, with watertight drafting; or, once it is too late and it becomes law, there is the propensity for problems, confusion and misinterpretation. 
 Paragraph 3(2) to the schedule states: 
''The constitution may also provide for the public constituency to comprise individuals who have attended any of the corporation's hospitals as patients''.
 However, as we know from the explanatory notes and the guide published in December, that provision is restricted to patients in the past three years. Can the Minister clarify whether ''the past three years'' start when the patient first goes to see a consultant to be considered for treatment or when the patient has completed his or her full course of treatment? 
 Paragraph 3(2) continues: 
''(including individuals attending as the carer of a patient).''
 That is an eminently reasonable inclusion in the Bill. I am relieved that the Government have decided not only to do that, but to include it in the Bill, so that everyone knows that that is their intention. However, the drafting is not precise enough for us to know exactly what the Minister means by the word ''carer''. Is it a good neighbour who pops in to see someone who is ill, makes him or her a cup of tea and does some shopping or cleans the house on a purely voluntary, good-neighbourly basis? Is it someone who is a fully paid, full-time carer for an individual? Is it a family member who cares for his or her partner, mother, father or child? Does it apply to people who look after children? Does it mean that those who classify themselves as carers—even if others consider them to be merely good neighbours—would qualify? If there is a dispute over whether a corporation believes that someone is a carer, as specified in paragraph 3(2), is there some form of appeal to resolve who is right and who is wrong? 
 To minimise the potential for disputes and disagreements, we are seeking, through amendment No. 144, to include a definition of ''carers'' in the Bill. It is a difficult and, some people might argue, unwise thing to do, because different people have different views of the role of a carer. 
 We have tried to get a definition that is acceptable to as many people as possible and we have that definition from Carers UK. That, I believe, is one of the best ways of trying to find a legal definition of a carer, if one is needed, to incorporate into legislation. Is it really our intention that those people should have the opportunity to become part of the public constituency? Would not that be the effect of the amendment?

Andrew Lansley: I hope that my hon. Friend will forgive me for not having asked this question separately. I am slightly perplexed as to why, in this context, Carers UK has included the reference to volunteers for a voluntary organisation as being, in effect, excluded from the definition of carers by virtue of the legislation. Why did it go down that path?

Simon Burns: I am slightly perplexed by my hon. Friend's question.

John Hutton: It is a good one.

Simon Burns: I thought that the Minister might say that, and no doubt he will brief his colleague, who will to reply to this debate.

Stephen Pound: I am anxious not to interrupt the mellifluous flow of the hon. Gentleman, but I am somewhat concerned. The word ''carer'' is specifically, exactly and precisely defined in the context either of welfare benefits legislation or the law in relation to a person's legal status to another person; whether they are the responsible adult, et cetera. We have a precise definition of the word ''carer''. The proposal contains vague expressions such as
''substantial care on a regular basis''.
 Those words strike me as being open to massive degrees of interpretation. I normally have great respect for the hon. Member for West Chelmsford, but on this occasion he is straining at a gnat. Why does he not accept that by moving the amendment he is in fact confusing the situation, when a precise legal definition, accepted by all, already exists?

Simon Burns: I do not agree with the main thrust of the intervention by the hon. Member for Ealing, North, because in amendment No. 144 we have gone to the best legal definition of a carer that we can get; that which has been supplied by Carers UK. My hon. Friend the Member for South Cambridgeshire is correct in saying that it would exclude a volunteer for a voluntary organisation, because that is aimed at individuals such as those who help with meals on wheels, who provide meals to a range of people during the day, and who would not be considered under existing legal definitions as carers in the context of what the Government are seeking to do in this paragraph. That is the explanation for paragraph 2(a) and (b).
 I hope that the Government will consider these two amendments, as well as amendment No. 97, with sympathy. I hope that the Under-Secretary will agree that despite what are undoubtedly the best intentions of the Government on the issue, they are leaving themselves and the legislation open to wide misinterpretation and confusion as to what they actually intend. When it comes to democratic processes—as in the democratic process for electing hon. Members to the House—the Government cannot afford to be generous and to leave too much to the interpretation of others where it may lead to a system that is not consistent throughout the country and that 
 is not seen by individuals in certain parts of the country to be fair and equitable.

Adrian Bailey: I endorse the comments made by others in welcoming you to the Chair, Mr. Atkinson. I want to contribute to the debate from a slightly different perspective, which is drawn from several years of employment experience in the co-operative movement, dealing with a huge range of co-operative societies. Some of those societies were big and others were very small, but they all had different rules of membership and so forth.
 First, there is a philosophical contradiction in a mutual or co-operative organisation if the centre tries to prescribe the exact requirements of membership. The essence of a mutual or co-operative organisation is that it has a local membership, and local people should construct the membership qualification, which suits the specific area and the organisation's specific functions. 
 I am the first to agree that there is always a danger that a group of people in the organisation could use the rules or membership structure to reinforce their position and exclude those from elsewhere. Obviously, mechanisms must be built into the legislation to prevent that from happening, and I assume that the independent regulator's assessment of the constitutions would aim to do that. 
 We have had a debate on the definition of the word ''carer'', and that debate indicated the complex and difficult waters one swims in if one tries to legislate too closely for the membership of locally based and locally run organisations.

Simon Burns: I wish to point out—I suspect that the hon. Member for Ealing, North (Mr. Pound) will be fascinated to hear this, given his criticism of some the words in our definition, such as ''substantial''—that this definition, which was supplied by Carers UK, is the same definition that his Government use to define carers in legislation.

Adrian Bailey: The whole point of my comments is that I do not want to get into a debate about such things; I do not feel that that is appropriate today. We have a rule, which is defined locally, that is inclusive and meets the needs of local people. That is why I caution against adopting a too prescriptive approach to the definition of membership, constituency, et cetera. In my experience of the co-operative movement, there is a wide range of membership qualifications, some of which are confined to people who are trading and some of which are confined to people who live locally.
 For example, the Leeds Co-operative society has one category for the local election of directors and another category for the national membership base. Different models might suit different foundation trusts and areas, according to the geography, the social composition of the area or even the employee composition, which has been mentioned, so I caution against trying to be over-prescriptive. We must have a regulatory regime that is inclusive and relevant to the needs of the trust, regardless of the constituency or membership qualification. That is a better way to deal with the issue than by over-prescription from the centre.

Chris Grayling: Will the hon. Gentleman give way?

Adrian Bailey: I have finished.

Patsy Calton: On behalf of the Liberal Democrats, I, too, welcome you to the Chair, Mr. Atkinson.
 The aim of putting the constituency together is to ensure that we deliver a locally accountable, decentralised public service. The question is whether all the concerns have been dealt with by all the various bodies that commented on this matter and whether a locally accountable service will be delivered. The public service will undoubtedly be decentralised, but the composition of the constituency may well determine whether we ultimately end up with a locally accountable body. 
 The Local Government Association has expressed concerns about many things, particularly the governance of the new arrangements. It is especially concerned about the setting up of a system that is parallel with local government, because there will be a duplication of the role of local councillors and, by extension, of the constituency that elects local councillors. Therefore, we will have different constituencies in the same area. 
 Those parallel mandates may cause a fragmentation of the public sector that would lead further to the sort of silo mentality in local government, from which we have been seeking to get away. Health, particularly hospital-provided health care, would be treated as something that is completely different from other sorts of public provisions, such as social care and so on, despite our attempts to bring health and social care together and to produce common features and partnership between the different providers. 
 I will not talk about the staff constituency; the amendments, except the final one, do not cover that. However, I should like to look at and comment on the amendments one by one. 
 I completely sympathise with the concern of the right hon. Member for North-West Hampshire that there should be some definition of what the public constituency should be. Leaving ourselves without some clear guidance for the foundation trusts will lead to a situation in which it is perfectly possible that although one foundation trust may get it very right indeed, another may fall between all the stools and get it very wrong indeed. 
 I have some concerns about—although some sympathy with—amendment No. 125, which states that the constituency should be defined as the geographical area served by a PCT. However, the Health Committee's report indicates that at least one—the Moorfields eye hospital—has 50 PCTs. Of those, no single PCT is responsible for more than 2 per cent. of Moorfields' income. There is a problem, which is not insurmountable, that clearly must be addressed. The tertiary sector is a special case. 
 In Stockport, the local authority, the PCT and what would be the foundation hospital—if Stepping Hill hospital achieved foundation hospital status—would be coterminous. Therefore it would be simple to define 
 the PCT as being the main one of the three. There are issues, and further exploration is required.

Simon Burns: I listened carefully to what the hon. Lady said. She referred to her local hospital, which was seeking foundation trust status. Given how she voted last week, will she be kind enough to tell the Committee whether she supports that application?

Patsy Calton: I am happy to say that in the round I support it. [Interruption.] I am happy to explain why I am willing to support it. I was on a governing body a few years ago when specialist schools were introduced. I remember being the only member of that governing body who argued at the time that although none of us was in sympathy with the specialist school status, nevertheless, when it was the only show in town and the only way to get what one wanted, it may well be what one should support. More recently, when the school realised that it was not going to get some of the additional funds that it required, in spite of its antipathy towards the idea of a specialist school status, it nevertheless went for it with the wholehearted support of the governing body.
 We can all modify our opinions according to local circumstances. I am sure that the hon. Member for West Chelmsford will be happy to explain why he is not prepared to ensure a way forward that will obtain new hospital facilities for his constituents. I am also sure that he will be happy to explain why his fundamental opposition to the principle meant that his party was not prepared to vote for a measure that would improve the lot of his constituents.

Peter Atkinson: Order. I am happy for the hon. Lady to explain her position on that matter, but we should not have a full-scale debate on it. I should like her to return to the amendment.

Patsy Calton: Thank you, Mr. Atkinson. I was giving as full an answer as I thought the question deserved. I see no inconsistency in my position; my constituents always come first.

Simon Burns: On the one hand; on the other—

Patsy Calton: On the other hand—[Interruption.] I am answering the hon. Gentleman's sedentary comments. In our area, the public like—

Peter Atkinson: I ask the hon. Lady to return to the amendment.

Patsy Calton: I am happy to do so if the hon. Gentleman will confine his remarks to when he is in an upright position. [Laughter.]
 Amendments Nos. 175, 118 and 144 all attempt to deal with the same issue, which is that users of the facility should be permitted to be members of the constituency. That seems entirely right, although some people might take issue with aspects of it. However, I agree with amendment No. 175, which was tabled by the Liberal Democrats, that patients and carers ''shall'' be eligible. It could not be right for patients and carers to be ineligible, which is what the word ''may'' implies. 
 It is also right that family members who are significant carers should be involved, and it is right to limit the definition of a carer, in that those who are not paid or who are not from recognised voluntary organisations should not be counted as carers in this sense. I will reserve judgement on whether staff who are eligible for the staff constituency should not also be qualified as both geographical members of the area, either patient-qualified or carer-qualified. It is a great pity that someone should be prevented from acting in a certain way. They may be patients, they may be carers, and I think it is possible for someone—[Interruption.]

Andrew Lansley: I am slightly surprised by the hon. Lady's argument, which seems to be inconsistent with the support of her hon. Friend the Member for Oxford, West and Abingdon (Dr. Harris) for amendment No. 119; an amendment for which she also expressed support. Does she not recognise that it is important that the legislation defines the boundary between the public constituency and the staff constituency? That is particularly important, as one of the most important consequences to flow from the definition of the public constituency is that someone in it could be elected as a non-executive director of the board. It would be an undesirable step for a member of the staff of the corporation to be elected as a non-executive director of the board also.

Patsy Calton: The hon. Member for South Cambridgeshire and I must agree to differ on the matter. I have seen and understood the argument before, particularly as it relates to governing bodies of schools, and I do not see why being qualified in one respect should prevent one from being a member in another respect.
 A series of issues need to be addressed. The Health Committee and several respected bodies and organisations have made it clear that they are not happy about the lack of definition of the word ''constituency''. We are not happy that all of the people who should be capable of representing others will be able to do so. We are concerned that such people will not necessarily end up as members of the constituency under the Bill. It should be a reflective body.

Andrew Lansley: When you have a chance, Mr. Atkinson, to read the report of this morning's proceedings, you will observe that I expressed my pleasure in serving under your chairmanship. Further to that, I shall try not to strain your patience, as you have had to listen to me for an inordinate length of time already in this parliamentary Session. I shall also try not to make the same speeches that I made on the Communications Bill.
 Even at this late stage in the debate I shall speak to amendments Nos. 118 and 119, which stand in my name, and to amendment No. 175—notwithstanding the speech by the hon. Member for Cheadle (Mrs. Calton)—which stands in the name of the hon. Member for Oxford, West and Abingdon. 
 Although they are rather more at the detailed end of the debate, I will speak about the purpose of amendments Nos. 118 and 119. Both relate to 
 paragraph 3(2) to schedule 1, in which we are providing for the public constituency to be extended beyond those who live in a given geographical area. Amendment No. 118 is designed so that the text would read: 
''The constitution may also provide for the public constituency to comprise individuals who have attended any of the corporations hospitals as patients (including their family members involved in their attendance and care as patients, or other individuals attending as the carer of the patient).''
 You will observe, Mr. Atkinson, that amendment No. 118 is not intended to exclude anybody from becoming a member of the public constituency. I tabled the amendment in order to express a concern that if the definition of ''carer'' was anything other than on the most inclusive basis—my hon. Friend the Member for West Chelmsford illustrated the nature of the problem—it may have the effect of excluding families of patients at the relevant hospital from the public constituency. That is why the words ''care'' and ''attendance'' in the amendment are used in relation to the patient. The objective, as expressed in the guide, and as understood by foundation trusts, is to seek to encourage the widest possible participation by those who have a relationship with the hospital.

Stephen McCabe: I may have misunderstood this point and I would appreciate clarification. I sympathise with the hon. Gentleman's intentions, but I can envisage a circumstance in which a person is seriously ill in hospital and all 10 family members travel over from the Republic of Ireland to provide 24-hour care and support. Is it really our intention that those people should have the opportunity to become part of the public constituency? Would that not be the effect of the amendment?

Andrew Lansley: The effect of the amendment certainly would not be to exclude people who actively attended and cared for family members at a hospital.
 Where does the proposal come from? It comes from the consideration of circumstances at Papworth Hospital NHS trust in my constituency. The definition of a public constituency in relation to a special trust is likely to be especially important because the geographical constituency will not necessarily be large and will, indeed, probably be relatively small. Let me give an example. 
 Papworth is a cardiothoracic hospital, so someone who is admitted may not previously have exhibited symptoms. In effect, their care begins the day they are admitted with a heart attack or something of that nature, so their care takes place in the hospital. It would not automatically follow from that that their family members could be defined as their carers, because the hospital would be providing the care. However, their family members would be in attendance and would have a substantive relationship with the hospital. In practice, in the case of Papworth, it will be people such as members of the Zipper club—patients, or family members and friends of patients—who will be looking to be part of the public constituency. They regard themselves as having a close relationship with the hospital. 
 It is not the job of a foundation trust to write legislation, and no one in hospitals sees that as their 
 role. However, they do see their role—they would express this pretty straightforwardly—as ensuring that patients' families are an integral part of their care and follow-up care at the hospital and of the hospital community. Hospitals see themselves as treating the whole person, which includes the patient's family. All that I seek to do in amendment No. 118 is to ensure that the term ''carer'' is not be construed in a way that might exclude the family members of those who have been patients. 
 As we heard, amendment No. 119 is a little more complicated. Paragraph 3(3) is designed to provide that those who live in an area cannot be treated as part of the public constituency if they are also members of the staff constituency. It makes life easier when one can draw on circumstances in one's own parliamentary constituency, and more than 5,000 people work at Addenbrooke's hospital in my constituency. Many would be regarded as living within the geographical parameters of the public constituency, and it is not inconceivable that they would seek to become members of the public constituency if they could do so. They would then represent a substantial proportion of the corporation's voting membership in that constituency. That could significantly distort the intended relationship between the public and staff constituencies. 
 In that respect, paragraph 3(3) is fine, and I have no problem with it as it stands. I freely acknowledge that amendment No. 119 poses a second-order question in seeking to establish who is the carer of a patient. It is entirely possible that the carer is a member of the staff at Addenbrooke's; indeed, there may well be persons who define themselves as a patient's carer. It is important that such people are not swept up into the public constituency, and the amendment would prevent that from happening. That would close off the two most important ways in which members of staff might become members of the public constituency. 
 Of course, it would also mean—this is an unarguable and desirable proposition—that members of staff who were also patients at the hospital could not become part of the public constituency. I shall not rehearse my reasons at length, but I tabled the amendment because, unlike the hon. Member for Cheadle, I do not think that it is proper for it to be possible for members of staff to become non-executive directors of the foundation trust by virtue of their becoming members of the public constituency. That is the structure of the argument for the amendment; there is not much more to be said about it in that respect beyond an explanation of its purpose.

Evan Harris: I signed the amendment and I want to make it clear why I did so. The hon. Gentleman is right that one can do one thing or the other. Someone who is eligible for membership of the staff should either be precluded from being a member of the public constituency by virtue of their being a patient or a carer, or they should not be. The Bill is wholly inadequate in that respect, because it leaves the question open in some case but not in others. That is why I wanted to support the hon. Gentleman in probing the Government.

Andrew Lansley: I am grateful to the hon. Gentleman for his support for the amendment and I shall not cavil at it.
 I shall not dwell at length on other amendments, except to say that I have every sympathy for my right hon. Friend the Member for North-West Hampshire, because the purpose of the constitution should be to define ''public constituency'' for the relevant purposes. I am loth to go too far, and in that respect I rather hope that my hon. Friend the Member for West Chelmsford will not press amendment No. 125, because I would have difficulties with it for two reasons. In the context of—[Interruption.] The hon. Member for Ealing, North talks about splits. He is a fine one to talk after his vote at Second Reading, but there we go.

Simon Burns: The rebel amendment.

Andrew Lansley: I am promptly reminded by my hon. Friend of the amendment at Second Reading.
 In the context of an NHS trust such as Papworth, amendment No. 125 does not work. Papworth hospital is not the principal provider of hospital-based services for any primary care trust. However, there are other, subsidiary reasons. For example, the Addenbrooke's hospital would be the principal provider of hospital-based services in Newmarket, outside my constituency, despite the presence of West Suffolk hospital. We shall come on to discuss further aspects of that. I hope that the Committee will become thoroughly familiar with the geography of South Cambridgeshire and neighbouring counties before we are done. 
 On that basis, I hope that my hon. Friend the Member for West Chelmsford will not press amendment No. 125. However, I support and agree with amendment No. 97, the lead amendment tabled by my right hon. Friend the Member for North-West Hampshire.

Chris Grayling: Does my hon. Friend not think that hospitals such as Papworth are served by the following subsections, which allow patients and carers to become part of the constituency, while reflecting the fact that, for the majority of hospitals, it is desirable to define a broad geographic area from which patients can be drawn? Does not the Bill, with the amendment from my right hon. Friend the Member for North-West Hampshire, cover both eventualities?

Andrew Lansley: As usual, my hon. Friend asks a good question. I think that the answer is no. I would expect Papworth hospital NHS Trust's public constituency to consist primarily of patients, former patients, families, carers and so on, but the amendment would exclude virtually any geographical component as such, because no primary care trust would fit the category. However, the people who live around Papworth hospital regard their relationship with it as greatly important. That is not just because they work there; indeed, not that many people in Papworth Everard work at the hospital.
 At some point in the next few years—it might be in the next year or two—there may be a proposal for 
 Papworth hospital to be rebuilt and moved to the Addenbrooke's site. That would be a major shift in the configuration of services. The people who live around Papworth hospital might reasonably think that a measure designed to increase local influence over the configuration of services should give them a voice in the question of what happens to their hospital, which has been an integral part of the community ever since Papworth was established as a TB colony. I do not want to exclude the geographical basis of representation for special trusts and tertiary hospitals, as well as for general hospitals. As with the case of Addenbrooke's, it is important to get the balance between geographical representation and patient representation right. As the Select Committee observed, half of the applications are for hospitals that combine tertiary referral services with district general hospital services. We should not conclude that one or other ought to predominate. We must expect that there will be a substantial mix of geographical and patient-related representation in all hospitals.

Andrew Murrison: I have been following my hon. Friend's argument carefully. Does he agree that it is important to separate the relationship that people have with real estate from their expectations of receiving services from a hospital? He rightly alludes to the affection with which people regard their local hospital, but the services that they gain from those hospitals are surely more important. In the case of Papworth, the number of people from the immediate area who use its services is probably very small. I appreciate the sentimental attachment that people have to their local hospital. However, the important thing is what that hospital produces, and its customer base.

Andrew Lansley: My hon. Friend is right; he makes a fair point. Under current NHS arrangements, local people do not have a direct role, except through the oversight and scrutiny committee of the local authority. I believe that NHS foundation trusts should not be simply providers of medical services, in isolation from their relationship with the local community. If that is true for a district general hospital, it must be true for a tertiary hospital, because both organisations draw not only their personnel but their goodwill and support from the same well.

Andrew Murrison: There are many employers in my constituency. A Virgin Mobile call centre employs more than 1,000 people; the Bowyers pork pie factory employs something of the same order. People have a legitimate interest in those organisations and sometimes take a very firm view of what goes on there. That does not mean that they should be represented on the boards of those companies. Does he not see a parallel with the case he is describing?

Andrew Lansley: I see a parallel but, if we go down the route of argument by analogy, we will get into difficult territory. Are we talking about a locally accountable public service, or a company that is engaged in a purely commercial enterprise? Those distinctions make the analogy difficult to draw. What do we mean by local accountability? What are we setting out to do? Are we creating a mutual organisation of consumers
 and a mutual organisation of producers, or are we creating something that has distinct and unique characteristics that include direct local control? How relevant is local control to specialist tertiary hospitals that provide services on a regional and supra-regional basis?
 My local hospital, Papworth, provides a supra-regional service, but regards itself as being rooted in the community. That may be for very specific reasons. The whole village of Papworth Everard was created as a TB colony. It is a place where relatively large numbers of people with disabilities live; a place where the Varrier-Jones foundation and the Papworth trust provide specialist services to people with disabilities. All those relationships are complicated, and have an historical background. If we were to exclude the possibility that the constituency of a specialist hospital would include people in its local geographical community, I would regard that as misplaced with regard to the Papworth hospital trust. 
 There are other specialist hospitals; my hon. Friend the Member for Westbury (Dr. Murrison) referred to the Brompton earlier. The Brompton may conclude that there should be no place for a geographical basis of representation. I do not know; it is up to that institution to decide. In my view, the specialist tertiary centre at Papworth does have a geographical basis for representation as well as a wider public constituency. 
 From my point of view that was quite a useful and interesting digression, but I persist with my reservations about amendment No. 125. I have delayed the Committee longer than I intended, but I hope that Ministers and hon. Members will see merit in amendments Nos. 118 and 119 when we come to the relevant point in the consideration of the Bill.

Hazel Blears: I, too, would like to welcome you to the Chair, Mr. Atkinson. I am delighted to have the opportunity to serve under your chairmanship.
 It might be helpful, before dealing with the detail of the amendments to give hon. Members some idea of the process with regard to the various partners working together on governance. Both the hon. Member for South Cambridgeshire and the right hon. Member for North-West Hampshire have raised some important issues and matters of proper concern about trying to get the balance right between consistent guidelines—what constitutions should look like and contain, and the essential minimum elements we want—and drawing on as much local innovation, imagination and creativity as we can. It is not easy to get that balance right. 
 As well as pushing forward the frontiers of the legal model that we discussed under clause 1, we are genuinely pushing forward the frontiers of democracy by ensuring that, in order to reflect that legal model with the freedoms and flexibilities it contains, we also, as a corollary, have a new model of local accountability and local social ownership of that model. That will thoroughly connect the organisation to the local people that it serves, the people who work there, those who use it and the 
 taxpayers who pay for it. It is a fairly complex and difficult venture on which we are embarked, but one which is extremely worth while, and I genuinely think that it will result in better, more responsive services for patients and a better standard in the national health service. 
 The right hon. Member for North-West Hampshire is right that the Health Committee highlighted the issue of seeking to safeguard democracy. Every Government Member would want to ensure that our plans do just that. We do not just want to safeguard democracy, but enhance it through the way in which the national health service is administered and run. Our proposals allow a significant extension of local democracy in the models that we are introducing. 
 The hon. Member for West Chelmsford expressed his concern about the possibility of different membership criteria in different areas, which might cause concern among the population. Opposition Members have a decision to make about how much they really do support local devolution, decentralisation and diversity, and to what extent they want to hang on to the means of central control and prescription of the way that such organisations should operate. It is a difficult decision to make; we have clearly made our decision that, within the framework set out in schedule 1, we want to give local organisations the maximum freedom and flexibility to come forward with ideas for their constitutions. These will be judged and assessed to ensure that they are rigorous, representative and can deliver the sort of organisation that we want.

Simon Burns: I must say to the Under-Secretary in all kindness that that response is a non sequitur. If one takes the example of parliamentary elections, in each constituency, a local decision is taken by local people who go and cast a vote. However, the rules under which they take that local decision—a totally devolved power—are set by central Government to ensure that the decision is fair and properly organised. Exactly the same should apply to this local democracy, so that central Government interfere not in the operation of local democracy, but in the framework that determines who takes part.

Hazel Blears: We are not creating a new set of parliamentary or local government elections. We are trying to set up a series of organisations and institutions throughout the country that will vary quite dramatically in terms of the kind of constituencies and communities that they serve. We are seeking not simply a passive democracy in which somebody simply uses a vote, but a really active democracy in which people want to be part of an organisation. We are trying to create a different kind of organisation. It is not simply a matter of people casting their votes and then going away. We are seeking to retain people's active participation. We have embarked on a different journey. It is not simply a matter of a vote for an organisation of which somebody is then no longer part. The kind of organisation in question is distinct from that.

George Young: The Under-Secretary is pushing her luck. She has just developed an argument for maximum local autonomy in the style of administration in the NHS for a body that has not yet been elected. How on earth does she reconcile what she has just said with what her colleagues in another Department have done to local authorities? Local authorities are democratically elected bodies that were denied the opportunity of choosing their management style. They were told that they had to move to Cabinet-style government even though that was not what they wanted. How does she reconcile what her colleagues did with what she is telling us will happen in this instance?

Hazel Blears: I certainly recollect that in my local authority we went through a lengthy period of discussion and consultation about what kind of business model we should have. As I recall, some of the options were put to the public and discussed—in a vote—in thousands of newsletters throughout my community. There was certainly lengthy discussion and consultation on the appropriate form of governance for local authorities.

Adrian Bailey: Picking up on the issue of voting in local government, does the Under-Secretary agree that it is precisely because of the failure of so many electors to engage in local government that the Government have given local authorities a degree of discretion to change their voting structures in the locality to promote more involvement, precisely in the same vein as we are recommending for hospital trusts?

Hazel Blears: My hon. Friend makes an important point. In my constituency, we virtually doubled the turnout for the local elections. Clearly, the Government are increasingly establishing different forms of organisation. One example is the new deal for communities boards, many of which are achieving a higher level of turnout in their elections than is possible in local government. The whole idea of having a diversity of governance models in local and national Government is rapidly becoming a feature of the Government. They are eager to explore diverse democratic models.

Simon Burns: The Under-Secretary has completely lost me. On the example of local government, the hon. Member for West Bromwich, West (Mr. Bailey) mentioned different ways of physically voting, but the issue is changing different constituencies of people who may vote, which is completely different.

Hazel Blears: If the hon. Gentleman had taken notice of the second part of my remarks, he would know that I mentioned the example of the new deal for communities boards. He may not have one of those in his area. If he does not, he is missing out on one of the Government's tremendous regeneration projects. In those areas in which the new deal for communities is operating, people's interest in becoming members of the board, taking part in elections and becoming engaged with boards that are making a real difference in their neighbourhoods shows us the way in which we can re-energise democracy in the delivery of public
 services generally, which is what we are trying to do in the NHS.

Adrian Bailey: I agree with my hon. Friend about the different ways in which people engage with local government. Considerable powers have bee devolved to town committees and more locally embedded structures to ensure that they are closer to the people.

Peter Atkinson: Order. Before the Under-Secretary replies, I should say that I thought that we were debating foundation hospitals. Perhaps she will concentrate more on that than on systems of local government.

Hazel Blears: Indeed, Mr. Atkinson, I shall be delighted to do that. Let me reassure hon. Members about our concern to get the balance right. The right hon. Member for North-West Hampshire asked whether there would be national guidelines, templates and materials for trusts to use in drawing up their proposed governance structures under the schedule. A model constitution is being developed as I speak. We hope that it will not be prescriptive or definitive, but that it will contain a great deal of support and guidance for organisations.
 We have set up an external reference group—comprising people from organisations such as the co-operative movement, the Electoral Reform Society, the Institute of Directors, the Compass Partnership, various NHS charities and the Alzheimer's Society, plus a couple of academics—to help us to explore with the applicants for foundation trust status what good governance should look like, and what the essential elements of their constitutions should be. That group has already met and is working on a source book that will provide some support for the applicant foundation trusts, with which it will work closely. There is to be an event on 20 May at which prospective applicants will consider governance and draft constitutions. An implementation team will work with the trusts to ensure that they get their governance right. Each organisation that goes forward to the second stage of application, when it will be required to work on a much more detailed constitution, will nominate a governance lead to take the process forward.

Chris Grayling: Forgive me if I have misunderstood the democratic process, but is not the Committee debating the Bill, which will return to the House and then to another place? Is the Under-Secretary saying that trusts are spending money on applications for foundation status before the House has decided whether to grant hospitals access to foundation status?

Hazel Blears: No announcement has been made as to which trusts will go forward, so none is in the second stage of application, which is when a trust would prepare a detailed constitution. Trusts are not in a position to do that work. I was seeking to reassure hon. Members who had asked important questions about what kind of guidance would be available and what issues the constitutions should address. The schedule sets out a minimal framework, which we expect every constitution to use. People should then make local proposals about the membership, the register, the methodology of electing the board of governors, the size and composition of the boards of
 governors and management, the appointment of non-executive directors, the principles of remuneration, the responsibilities of the boards of governors and management and all the matters that will affect the futures of the organisations.

Jon Owen Jones: Will the Under-Secretary reassure the Committee that, in deciding on the criteria to be used to establish good governance, we shall not lose sight of a fact that the majority of the public would recognise; good governance is that which delivers efficient, reliable and safe service in as fast a process as possible?

Hazel Blears: My hon. Friend makes an important point. The Bill places a duty on the trusts to operate in an effective, economic and proper way in order to provide responsive services to patients. That is what this process is all about. There would be little point in going through it if we did not genuinely believe that connecting those organisations to the local community will drive up standards and ensure that services are available quickly and responsively. The Secretary of State has gone on record as saying that the system must work and that the process must be meaningful for the patients and the public involved.
 I should like to reassure Members that all the important issues in the constitution will be taken into account in the process. Chapter 2 of the guide contains a long section on what the governance should look like. It goes through who can be a member, who can be on the board of governors and who can be on the board of directors.

Andrew Lansley: Perhaps the Under-Secretary can help me with something that my hon. Friend the Member for West Chelmsford was discussing. The guide states that membership is open to
''people who live outside that area but have been patients in the previous 3 years'',
 but neither the explanatory notes nor, for that matter, the Bill refer to that qualification.

Hazel Blears: The hon. Gentleman is correct that several matters discussed in the guide have not been translated into the Bill. I will deal with the issue of patient representation and what the trusts choose to bring forward. It is not appropriate to put in the Bill an arbitrary cap on the period for which somebody should have been a patient.

Simon Burns: If I understand the Under-Secretary correctly, she says that the three-year rule has not been translated from the guide into the reality of the Bill. Does that mean that if one were treated in a hospital 30 years ago, one would be included?

Hazel Blears: If I may say so, the hon. Gentleman is guilty of hyperbole.

Simon Burns: The Minister of State told the hon. Lady to say that.

John Hutton: No, I did not.

Hazel Blears: I can think up four syllable words of my own volition.

Simon Burns: What is the answer?

Hazel Blears: The answer is that it is for a trust to decide what it wants to put in its constitution to define
 the public part of its constituency, which may or may not include patients. The right hon. Member for North-West Hampshire asked whether the definition would include one-off visitors to accident and emergency or out-patients. There may be different circumstances in which different groups of patients are included. The Liberal Democrats tabled an amendment that would have included all patients in all circumstances. There is a debate and it would not be appropriate to put an arbitrary 36-month cap in the Bill.

Stephen McCabe: I may have missed this in the Bill or in the notes, but is there a mechanism for people who think that the constituency defined by the trusts is wrong or inappropriate? How can people say, ''This is wrong. This does not represent my hospital. The wrong people have been given access to power''? Surely that is what people are concerned about.

Hazel Blears: Indeed, local people will be concerned to ensure that the post-draft constitution reflects their view of what is a representative body for their community. That is why the Bill states that when the second stage application is made, there will be a requirement to consult not only with local people but with the primary care trust and with partner organisations to ensure that there is broad support for the way in which the draft constitution outlines who shall and shall not be a member. There will be a local process to enable that to happen. The Bill also provides for the Secretary of State to make regulations on the nature of the consultation process to ensure that it is robust and vigorous so that people are entitled to have their say about the membership constitution before it is finally endorsed by the Secretary of State and the independent regulator.

Simon Burns: All through the Under-Secretary's comments, she has stressed that this is a great devolving power to allow trusts to make decisions. All of a sudden, she has slipped out that the Secretary of State will issue regulations guiding trusts in certain areas. Her argument is a contradiction in terms. On the one hand, she claims that the power will be devolving and that everyone will make their own way and their own decisions; on the other—this is typical of the Government—she says that the Secretary of State will issue regulations to tell trusts how to behave.

Hazel Blears: I believe that the hon. Gentleman would be the first to admit that the regulation-making powers in the Bill are scarce; they are hard to find. It is perfectly proper that there should be regulations about the process of consultation but not regulations that prescribe the content and substance of the proposals. That distinction may be a little too subtle for the hon. Gentleman, but I commend it to him, because I genuinely believe that it is about getting the balance of democracy right.
 The process ought to be one in which people have a proper opportunity to influence whether the proposals proceed to the next stage and whether they are founded on principles that gain a wide measure of respect in the community. It is not for the Secretary of State to prescribe the detailed content of the proposals, 
 which properly ought to be left to local consideration. That is an important distinction, although, as I said, perhaps it is too subtle for the hon. Gentleman. 
 I also commend to hon. Members section 7 of the guide, which sets out the application process and the support that will be offered. Hon. Members have expressed concern about the support that will be available to applicant trusts to enable them to take on the burden of connecting in a democratic fashion with their local communities as well as running the core services of a hospital trust. It is important to keep in mind that this will be a new venture for many NHS foundation trusts. 
 I am delighted that many trusts are enthusiastic and willing partners in the venture. I look forward tremendously to their having an opportunity to engage local residents and patients in designing the services, but I freely admit that they will need help and support to enable them to do so. That is the purpose of the external reference and implementation groups that will be set up to help on a day-to-day basis. We genuinely want to get to a point at which the democratic element of the proposals is robust and effective in driving standards and the responsiveness of services. We want the process not for its own sake but for a purpose.

Chris Grayling: Who will pay for all this? The Under-Secretary has described a process of consultation with the public and constitutions, in which each trust will be able to define its own constitution and have total freedom, effectively, to form its own constituency. There is no doubt that each trust will need legal advice to do that, resulting in a big bill. Where will the money come from?

Hazel Blears: Obviously, we will try to ensure that the process is carried out as economically as possible and that we share knowledge and practice. We certainly do not want every individual applicant to go down its own path, seek its own advice and duplicate costs if it is not necessary to do so. We will seek economies of scale across the board.
 However, democracy has a price. It is a price that the Government absolutely believe is a good investment for the future. If local services can be connected to local communities, people will feel a sense of ownership and will fight for, protect and nurture the services in a way that they would never do without the feeling that they were a member with influence, power and ownership. Organisations that take this route will find that money is extremely well spent because of the way in which they will be able to configure their services. 
 I am sure that we all agree that people who work at the sharp end of organisations often can make the best suggestions about how the organisation should operate and that a great deal of money could be saved by making such changes. The Bill provides a marvellous opportunity, certainly for staff at the front line, to shape the design of the services.

Andrew Murrison: My hon. Friend the Member for Epsom and Ewell (Chris Grayling) makes a good
 point. The Under-Secretary surely must have done some sort of a regulatory impact assessment and must have a ballpark figure for how much the proposals will cost. It would be extraordinary if she did not. Will she share that with the Committee?

Hazel Blears: We have said in the guide that there will be extra resources available to help with the process, because it is a new process and it is right that it should be taken forward. I do not have a global figure because we are in the early stages. I have no doubt that, as the process continues and we get to the second and third waves, there will be economies of scale and some central administration, thereby minimising the costs. We do not want to incur extortionate costs for the process. We want to spend enough money to ensure that it works and is effective, and that it is a real process of engaging members rather than a sham organisation that does not achieve what we want.
 I think that I have said enough about the amendments in general terms. Amendment No. 97 would require the constitution to define the public constituency. I am sorry to tell the right hon. Gentleman that the amendment is unnecessary. It is not that I dislike it, but the schedule requires the constitution to define the public constituency. Paragraph 3(1)(a) states that the constitution shall set out the public constituency. It was important to make the point about defining the public constituency, but the constitution will have to put that forward and the public constituency will vary from some of the examples we have heard today. It may be one local authority area or two, depending on patient flow and the constituency that the organisation serves. That is sensible because the public constituency must reflect the people who feel a genuine stake in the organisation. The constitution will define the area and will be subject to assessment by both the Secretary of State and the independent regulator when deciding whether that application should go forward as having a sufficiently robust constitution. 
 Amendment No. 125 is, I am sorry to say, unacceptable also because it would circumscribe the area of the public constituency into an area covered by a primary care trust or family care trusts, which are principal providers. It is difficult to define accurately what a principal provider would mean in practice and there is an enormous range of primary care trusts with which prospective NHS foundation trusts could have contracts; it could be from one PCT to practically all of them. The right hon. Member for North-West Hampshire cited the example of Moorfields eye hospital. In that case, services commissioned from any PCT amount to no more than 2 per cent. of any activity of an individual primary care trust. A small number of patients may be involved, but the hospital may be a principal provider in its particular field of clinical activity for most if not all PCTs in the London area because that is where they seek to refer their patients. 
 To give a contrasting example, services commissioned in the North Tees and Hartlepool NHS trust account for 62 per cent. of services provided for Hartlepool PCT, 48 per cent. for North Tees PCT, 34 per cent. for Easington PCT and only 9 
 per cent. for Sedgefield PCT. That trust is the principal provider for Hartlepool PCT and could account for more activity than any other single provider for North Tees and Easington PCTs, but, clearly, not for Sedgefield PCT. There are a variety of circumstances and it is not appropriate to try to circumscribe that matter in the Bill. The amendment would be confusing, impracticable and unworkable and I suggest that it should be rejected. 
 Amendment No. 175 would provide that all patients should fall within the public constituency part of the constitution. Again, that is not appropriate. NHS foundation trusts should have the flexibility to shape their constitutions to meet individual circumstances. Some specialist centres take patients from all over the country. Many teaching hospitals provide a wide range of services to people outside the area. The hon. Member for South Cambridgeshire gave the example of Addenbrooke's and Papworth hospitals; in both cases, it might be appropriate to include patients and carers from outside because they are specialist trusts. 
 My local hospital has a neuroscience centre for the whole north-west of England and it may be appropriate to take patients from outside the area. Other trusts provide almost all their services within a well-defined geographical area and may provide the one local hospital. In that case, it might not be necessary to include provision for patients who live outside the area. It is a matter of horses for courses. They may treat a small number of patients who come on holiday or pass through while at work, but that will be a matter for local constitutions to deal with, so it is inappropriate to put that in the Bill. 
 Amendment No. 118 seeks to define further the definition of carer to include the families of patients who have been treated. We have included provision for the carers of patients to be eligible for NHS foundation trust membership. When a patient is too ill or unable to carry out their duties as a member or governor, a carer can do that in their place, which is perfectly proper. A patient's principal carer will often be a family member. To extend that further by allowing other people in the family to become members of the NHS foundation trust would allow a single patient to exercise undue influence through the multiple votes of their family, so we shall reject that. When the carer of the patient is a member of the family, they will be entitled to be a member of the public constituency, but we would not want that to be extended to the whole range of family members who may at some point be involved in the care or attendance of the patient. I can imagine a situation in which an extended family of perhaps 10, 15 or 20 members might be involved and that, clearly, would be excessive.

Andrew Lansley: If the amendment referred to spouse or partner, would the Under-Secretary feel differently? In the context of the Zipper club at Papworth, which I know well, a spouse or partner may remain a member of the club and active while their spouse or partner is alive and sometimes after they have died. They feel that they have a relationship with the hospital in the long term.

Hazel Blears: If the carer is a family member, they will be included in the public constituency by virtue of paragraph 3(2), which meets the point. We do not want to extend that to people who have simply been involved in care. When the carer is a family member, they would be covered by paragraph 3(2) which states:
''The constitution may also provide for the public constituency to comprise individuals who have attended any of the corporation's hospitals as patients (including individuals attending as the carer of a patient).''
 There is no provision to exclude a family member, provided that he or she is a carer.

Andrew Lansley: Provided that he or she is the carer of the patient. I gave the example of a spouse or partner of a patient attending a hospital and being cared for by the hospital; perhaps there was no care in the community and perhaps the spouse or partner simply attended the hospital while the spouse or partner was an in-patient. I am worried that the definition of carer will be tight and will exclude close family members who attend at a hospital.

Hazel Blears: I understand the hon. Gentleman's point and it is a question of getting the balance right and not allowing a single patient to have a whole range of family members eligible to vote in a public constituency simply because of a tenuous connection with the patient. That is an indirect way of becoming a member of a public constituency and we must not stretch those indirect connections too far so that they have no legitimacy. What I say about carers may reassure the hon. Gentleman in terms of the circumstances that he outlined.

Evan Harris: The Under-Secretary is concerned that extending membership of the public constituency to members of the family of patients who live outside the area defined will distort the voting mechanisms. She envisages a situation in which so few people will enrol as members from the local area, which may consist of 40,000 or 50,000 people, that the small number of patients whose relatives have strong views because they see the situation through the eyes of the relatives and carers might distort the quasi-democratic process. Is that what she is saying?

Hazel Blears: No, and the hon. Gentleman knows well that that is not what I propose. I certainly do not envisage that there will be so few members. I envisage that there will be many many members of these organisations. However, it is right to try and draw the line in an appropriate place. I shall comment on the definition of carer, but where a family member is a carer, the definition should be flexible and open to change. Where family members become involved in the care of patients, they would be eligible to become members of the public constituency.

Stephen McCabe: This is difficult, but I think that my hon. Friend makes a reasonable case for saying that we have to have some safeguards to ensure that individuals do not exert undue influence, even with multiple family members. That is a fair point.
 Since we do have that concern, how can we make sure that other organisations do not exert undue influence through organised multiple membership? An example that springs to my mind is this; what would 
 we do if an organisation like the Society for the Protection of the Unborn Child recruited a host of individual members in an area and then sought to influence the policy of the hospital? What safeguards exist there?

Hazel Blears: My hon. Friend makes an important point. Several hon. Members have asked how do we avoid capture by these organisations? Other people have referred to it as entryism. It will be one of the things that tests and challenges these new organisations. Obviously the members have the right to elect the board of governors. The way the board is structured will be crucial to try to ensure that no single organisation has the right to elect a significant proportion of that board of governors. The public constituency will have an absolute majority on that board. The staff will also be represented, as will partner organisations, the PCTs and possibly the universities.
 When assessing the constitutions that are submitted as part of second stage applications we must be very careful to ensure that there is an appropriate balance in the way that those governors are elected from the broader membership. Again, it would be wrong to exclude from the broader membership people who want to be active in the public constituency. I hope that will maximise the number of people in the broader membership, and that we try to make sure that the board of governors is a manageable organisation that perhaps will not have more than two or three people from a particular group. 
 Sitting suspended for Divisions in the House. 
 On resuming—

Hazel Blears: I think that I had finished dealing with amendment No. 118 in relation to the family members. Amendment No. 144 strictly defines who would be a carer.

Evan Harris: Before the Under-Secretary continues her remarks, I am still surprised by her view that to extend the franchise, if it can be called that—although I think that that is dubious—to family members of patients would be a distortion. She says that if the boundary were drawn along a certain line and there was a patient with a large family living inside that line who was a member of the public constituency anyway, there would be 10 potential members and therefore votes for that family. However, simply by virtue of living just outside the area—even if that family had greater concerns and experiences of the treatment of their loved one—those family members would not be allowed to become members. Such geographical variations cannot be justified. The Under-Secretary has been known to refer to them as a postcode lottery.

Hazel Blears: I understand and appreciate the hon. Gentleman's point. He says that it is arbitrary to draw a geographical boundary. I am sure he would accept that all Members have indicated that it is vital for the public constituency to be defined. Some Members have
 said that they would like it to be defined in legislation; others have said that they are content for that definition to be brought forward by the organisations.
 There is widespread agreement that the public constituency needs to be properly defined by reference to an area as well as by reference to patients in order for there to be certainty about the boundary for the membership. Without such certainty we could be led into all kinds of difficulties. 
 We have sought to accommodate the position where there is a carer of a patient from outside the area, because they have a legitimate role to play where the patient is too ill or not capable of exercising his rights as a member of the public constituency; therefore, the carer should have the opportunity to do so. Where the carer is a family member, they will be included in the public constituency. 
 The hon. Gentleman wants to go further; he is seeking to have it both ways. Had he been here for the earlier debate he would have listened to the contribution of his colleague the hon. Member for Cheadle, who indicated that we can all modify our opinions for local circumstances. The hon. Gentleman is in danger of falling into the same trap as his colleague; seeking to have a defined area and then saying that if someone falls just outside that area they should have a right to participate. I am afraid that there are rules and regulations and this is one of them. Unfortunately the hon. Gentleman cannot—as most Liberal Democrats like to—have his cake and eat it.

Simon Burns: I am interested in the hon. Gentleman's intervention on the Under-Secretary where he mentioned the phrase ''postcode lottery''. Does the Under-Secretary remember the debate in Westminster Hall a few weeks ago on the National Institute for Clinical Excellence when the hon. Gentleman told the hon. Members present that he had never used that expression, either as a parliamentary candidate or an MP? He has either forgotten that, or he is now changing his ways.

Hazel Blears: I recall that debate, but I do not think that it is the subject of the amendments before us today.

Andrew Murrison: The Under-Secretary has talked about a geographic qualification. I am concerned slightly about an attendance qualification—I am sure that is something that she does not intend—because line 17 specifically mentions individuals attending as the carer of a patient. In amendment No. 118, my hon. Friend the Member for South Cambridgeshire has moderated that somewhat, and the amendment would make it less mandatory.
 To be represented, one has to have attended and the implication is that that would be a physical attendance. I am sure that that is not the Under-Secretary's meaning because she will be aware that people can access hospital services without having attended. We might consider itinerant clinics, or clinics being run in community hospitals, for example, for which acute NHS trusts are not responsible. We might even consider itinerant clinics as far away as the channel islands being run by Southampton university's NHS trust.

Peter Atkinson: Order. This is a long intervention, and I hope that the hon. Gentleman shall bring it to a close.

Andrew Murrison: I shall bring it to a rapid conclusion. I think that the attendance qualification implicit in the Bill needs to be tweaked in such a way that people who do not physically attend, and their carers, have the chance of representation.

Hazel Blears: The hon. Gentleman makes an interesting point. Sub-paragraph (2) says that the constitution may also provide for the public constituency to comprise individuals. We would expect to see proposals in the constitution for those trusts that want to include patients, explaining how they would envisage that operating in practice. With the advent of telemedicine and certain forms of information technology, which are increasingly used in the service, the word ''attended'' may well need to be tweaked, as the hon. Gentleman says. That is the kind of connection in the use of services that we want to ensure. It should not be a matter of going to the hospital itself; people should be involved and accessing services.

Andrew Murrison: It is a pedantic point, I know, but the wording does specifically say ''attending''. In a legal sense, that must be examined to ensure that the constituency to which I have referred is not excluded by a clever lawyer. I should be grateful if the Under-Secretary considered the matter a little further.

Hazel Blears: I take the hon. Gentleman's point about the word ''attended''. I will certainly examine the various definitions of the word to establish whether one's physical presence is required or whether it could be interpreted in a different way. I will undertake to examine that. The sense of the provision is clear—having access to services of the organisation—but I will consider that matter.

Evan Harris: The Under-Secretary's response to my last intervention was silly because the point that I was making was not that there should not be a line. Clearly, when there has to be a line, there will be an arbitrary distinction on the basis of where one lives. However, if one is bothered enough to be a patient, and has that sufficient interest, surely it is not unreasonable, as the amendment proposes, to extend the franchise to family members of that patient, even though they live outside the line. I am not saying that there should not be a residential qualification, and the Under-Secretary knows that that is not what I am saying.
 If one is already a patient, even living outside the line, there will be no distortion because the numbers are small and one has a sufficient interest. I am asking the Under-Secretary how she can justify excluding those people. That is not trying to have it both ways and she knows it.

Hazel Blears: As I have explained, the line has to be drawn somewhere, and the amendment would take us into areas where the connection would become ever more tenuous. As I explained in my response to the hon. Member for South Cambridgeshire, where the carer is a family member, he or she will be included. As far as other members of the family who are not carers
 are concerned, there is a possibility of their being not close family or a spouse or partner, but part of an extended family.
 We could find ourselves in the circumstance where an individual patient who is not a resident of the area could be a member of the public constituency and could bring a whole host of relatives into that constituency. It is important to maintain the integrity of the membership base and the franchise. It will be a franchise because members of the trust will have the right to vote and to elect members of the board of Governors; that is serious democracy. We must not extend the boundaries so that they become amorphous and virtual instead of real. It is right and proper to draw a line. We want to be inclusive, but that must be in the context of those who meet the definition set out in the legislation. That is why we reject amendment No. 118. 
 Amendment No. 144 is an attempt to define a carer. To do that would be to remove the flexibility required to reflect the changing nature of carers. As families, and the way in which people organise their lives, change, it is right not to define carers in this context. We would expect NHS foundation trusts, as leading organisations in the national health service, to follow best practice in recognising the role of carers. I am sure that they will. We must allow them the flexibility to take account of differing circumstances. Caring affects millions of people in differing circumstances. It is not appropriate to include in the Bill a statutory definition; local organisations should make their own proposals regarding carers.

Simon Burns: If that is the case, why have the Government included that definition in their draft Mental Health Bill, and why was it in the Carers and Disabled Children Act 2000?

Hazel Blears: The definitions—not just of carers but of a range of individuals who access services within the national health service—vary depending on the nature of the relationship. Contractual arrangements, consumers of services and people who pay for services are different in different contexts, so it is appropriate for there to be different legal definitions. In the context of this democratic framework, if a patient is too ill or incapacitated to exercise his responsibilities as a member or as a governor, his carer will be considered to be a member of the public constituency. That is not a contractual relationship, as is the case for some carers, so it is appropriate for the organisations concerned to develop their own definitions. It would be unduly restrictive to set out a statutory definition in the Bill.
 I am sorry to say to the hon. Member for South Cambridgeshire that amendment No. 119 is unnecessary, although it is carefully drafted. The legislation already achieves the suggested effect of the amendment, which is to prevent individuals who are part of the public constituency—because they are patients or carers—from voting in the staff constituency. The hon. Gentleman is right to make the distinction; the separate constituencies need to keep their integrity. There should not be a crossover—

Andrew Lansley: I think that the Under-Secretary has it the wrong way round. It is designed to stop people who are members of the staff constituency voting in the public constituency, not the other way round.

Hazel Blears: They are mutually exclusive, so there is a corollary between those two lines of argument. Paragraph 3(3) says that
''Sub-paragraph (1)(a) does not apply to a person who is eligible for membership of the staff constituency.''
 The key word is eligible. In no circumstances could somebody who is eligible for the staff constituency—in that he is an employee—be in the public constituency. The first qualification is eligibility. It does not matter if he is also eligible for the other constituency; he cannot be a member of it. Sub-paragraph (1)(a), which concerns eligibility for the public constituency, does not apply to somebody who is eligible for the other constituency. A staff member cannot elect to be in one constituency or the other; that is where he stays and he cannot cross over.

Andrew Lansley: I am not persuaded by the Under-Secretary. The whole point of sub-paragraph (1)(a) is that it defines the public constituency by reference to an area. Sub-paragraph (2) goes on to allow for exceptions to that. There is nothing in sub-paragraph (3) as it stands that says that someone who is eligible for membership of the staff constituency is excluded from the further provisions in sub-paragraph (2) for the public constituency. All that sub-paragraph (3) says is that someone who is a member of the staff constituency cannot be part of the public constituency by virtue of where that person lives. It does not exclude the provision in sub-paragraph (2).

Hazel Blears: I do not accept the hon. Gentleman's point. As I read the provisions, sub-paragraph (2) is a qualification of sub-paragraph (1)(a). Sub-paragraph (1)(a) states that someone can be in the public constituency if they live in the area and sub-paragraph (2) states that someone can also be in the public constituency if they are a patient or a carer and if that is what the constitution provides. Sub-paragraph (3) states that someone cannot be in a public constituency—whether that is the original public constituency or the additional public constituency comprising patients and carers—if they are eligible for the staff constituency. That is how the legislation must be read.
 The legislation is in consecutive form. One reads sub-paragraph (1)(a) and that is then qualified by sub-paragraph (2), if that is provided for in the constitution. Sub-paragraph (3) goes on to state that sub-paragraph (1)(a)—sub-paragraph (2) augments the public constituency by adding patients and carers—does not apply if any of the people are eligible for the staff constituency. If they are eligible for the staff constituency, they are not eligible to be in the public constituency. That is my interpretation. Does the hon. Gentleman accept it? [Interruption.] He is not coming back to me, so I presume that he does. I ask him to read the provisions consequentially. That is their legal effect. 
 That effectively deals with all the amendments. We have had an extremely interesting debate on the definition of the public constituency. I am sure that we will go on to debate matters in the constitution as we proceed.

George Young: The Under-Secretary made a genuine attempt to reply to the points raised in what was an interesting debate. I hope that she is promoted rapidly to Minister of State in the Office of the Deputy Prime Minister, where she will restore to local government some of the freedoms that the Government have taken away and in which she clearly believes.
 At the end of the Under-Secretary's speech, I was left feeling that there were one or two loose ends. I also feel slightly confused as to the Government's position on the balance between, on the one hand, consistent guidelines and getting the essential minimal elements and, on the other hand, allowing local responsiveness. She said that we were talking about a new model of social ownership. I am sure that that is the case, but I feel a twinge of sympathy for the people running the trusts. They thought that they were being appointed to run a hospital. Now they find that they are running a roadshow and that they are part-time electoral registration officers. They will have to deploy a whole range of skills to develop a new model of social ownership—to use the Under-Secretary's words—at the same time as running a hospital. 
 Will the Under-Secretary explain whether the people running the trusts will be compensated for that? Page 71 of the explanatory notes concedes: 
''Modest start-up costs are likely to be incurred by those seeking NHS foundation trust status.''
 It continues: 
''The Secretary of State will have the power to give grants to NHS foundation trusts as he currently does for NHS trusts.''
 Will the Under-Secretary say whether those who are going through the process are getting any extra funds this year from her Department to meet the extra costs of defining the public constituency, which is clearly a burden that they did not anticipate? 
 Having developed the first part of her speech, which was devolutionary, the Under-Secretary changed gear half way through and went into prescriptive mode. She said that she was working on a model constitution. Will she explain how people will be obliged to take the model constitution into account? I cannot find in schedule 1 any reference to the Secretary of State making regulations or giving guidance on the constitution. We heard that an external reference group has been set up and that it will produce a model constitution, which will address some of the issues that we have been debating. However, I am not sure how that then bites on the process in which the trusts are engaged under schedule 1. 
 There is another important point about the external reference group. The Select Committee did not seem to know anything about it. When the Select Committee concluded its report on 29 April, it criticised the Government for not producing any guidelines. The Under-Secretary has told the Committee that an external reference group will do what the Select 
 Committee asked. I wonder whether she drew the attention of the external reference group to the Select Committee, which is clearly concerned about the absence of national guidelines. 
 At some point—it may not be in this sitting—will the Under-Secretary explain the time scale? The external reference group is beavering away and will produce some guidelines. We have not been told when those guidelines will be produced but I imagine that they are not imminent. The trusts must follow a time scale if they are going to be assessed in September this year by the panel of experts drawn from inside and outside the Department of Health. If one examines the Select Committee report, trusts that want to apply for first-wave status will have six months to consult and to prepare plans, which they must do by September this year. 
 As I understand it, the trusts will not have the guidelines for some time. How on earth can they produce a constitution, including a definition of the public constituency, by September when they will not know the national framework for some time? I get the impression that there are some loose ends. If not now, then in a subsequent sitting, we should like to hear whether the Under-Secretary accepts the Select Committee's view that the Government must produce a national set of guidelines specifying the rules for defining membership of constituencies and the process for managing elections to allow NHS patients and the public at large to have confidence in the process. Is she a full subscriber to the Select Committee's aspiration? 
 There are some loose ends and it is appropriate for the Committee to record its anxiety about them. If my hon. Friend the Member for West Chelmsford is not wholly persuaded that amendment No. 97 is the perfect choice to take into battle, I would ride behind him on alternative amendment, if that were his advice.

Simon Burns: I hate to adopt what the Under-Secretary might consider to be smug mode, but I remember another occasion on which the Criminal Records Bureau was debated. I warned the Government that they were making a ghastly mistake not on the principle of the policy but on the implementation of its nuts and bolts because the time scale was too problematic. Listening to the Under-Secretary and my right. hon. and hon. Friends during the course of the debate, that memory came flooding back to me because this problem is the same. The Government have got into a terrible tangle and I warn them that I have a horrid suspicion that despite their good intentions the process will be a frightful mess because it is uncertain, loosely proposed and contains many possible changes and differences from area to area, which will cause confusion, resentment et al.
 I wish that the Government would think again because we want to pass good law rather than bad law, which will end in a fiasco. In the case of the CRB, the right hon. Member for Barrow and Furness, the current Minister of State, Department of Health, had moved on and the hon. Member for Redditch (Jacqui Smith) had to listen to my kind words of sympathy. 
 I want to withdraw amendment No. 125, although I should like to put down a marker that we may want to return to it on Report. I should like to push amendment No. 144 to a Division because, notwithstanding what the Under-Secretary said, defining ''carers'' on the face of the Bill would be an improvement, which would strengthen the cause of carers. All too often throughout the history of caring, carers have had to hit their heads against a brick wall and fight for the help that they need.

Hazel Blears: To respond briefly to the right hon. Member for North-West Hampshire, the trust will get extra support and funds. We shall make an announcement on that shortly. The trusts to go forward to the detailed application point of the second stage have not yet been announced, but they will need extra support and assistance to be able take on the additional duties. Many are enthusiastic about taking on the extra area of work, because they see it as integral to their success as locally driven and managed organisations.
 The model constitution is being worked on now and should be available fairly shortly. It will not be a statutory constitution; nowhere in the Bill does it say that the constitution must be used. However, the source book is being prepared by the external reference group, which is considering good governance in a range of sectors from social enterprise to co-operatives, companies and other organisations. That experience will be drawn on to give support, so the model will be helpful. 
 We shall respond to the Select Committee in detail, which is the Government's normal procedure. However, I do not subscribe to the view that the system proposed is fragmented and will lead to inequity. The system will lead to good governance and good local management, which will drive services. 
 In response to the hon. Member for West Chelmsford, I would not accuse him of being in smug mode. The mode that he is in now is surprising to me; it is a timid mode and he lacks self-confidence. We are embarking on a bold, radical, exciting and worthwhile course of action. If the hon. Gentleman feels that the relevant organisations cannot sort out local good governance and democracy, he does not have the confidence in them as the leaders in the national health service that I have. Speaking from the party that introduced the Child Support Agency and the fiasco and chaos that went with it, the hon. Gentleman is hardly in a position to lecture the Government about putting systems in place. I have absolute confidence that the NHS will respond in a magnificent fashion, of which it has a history, and will embrace the new democratic agenda with enthusiasm and imagination.

Peter Atkinson: Order. The Committee has not yet disposed of amendment No. 97, which is the lead amendment.

George Young: I beg to ask leave to withdraw the amendment.
 Amendment, by leave, withdrawn.

Peter Atkinson: It has been indicated that the official Opposition wish to have a vote on amendment No. 144, but that will come after the Committee has debated and dealt with Government amendments Nos. 152 and 153.
 {**?tw=98%**}Further consideration adjourned.—[Mr. Fitzpatrick.] 
 Adjourned accordingly at twelve minutes past Five o'clock till Thursday 15 May at five minutes to Nine o'clock.